2015 Ibd

World Gastroenterology Organisation Global Guidelines
Inflammatory Bowel Disease

Update August 2015
Review team
Charles Bernstein
Abraham Eliakim
Suleiman Fedail
Michael Fried
Richard Gearry
Khean-Lee Goh
Saeed Hamid
Aamir Ghafor Khan
Igor Khalif
Siew C. Ng
Qin Ouyang
Jean-Francois Rey
Ajit Sood
Flavio Steinwurz
Gillian Watermeyer
Anton LeMair
Canada (Chair)
Israel
Sudan
Switzerland
New Zealand
Malaysia
Pakistan
Pakistan
Russia
Hong Kong, China
China
France
India
Brazil
South Africa
The Netherlands
WGO Global Guidelines
IBD 2
Contents
1
Introduction 3
1.1 Global incidence/prevalence and EastWest differences 3
1.2 Presenting features of IBD EastWest differences 4
Clinical features 5
2.1 Symptoms 5
2.2 Complications
Diagnosis of IBD 7
3.1 Patient history 7
3.2 Physical examination 8
3.3 Laboratory tests 9
3.4 Imaging and endoscopy 11
3.5 Diagnosis in pediatric patients
13
Cascade for IBD diagnosis 13

4.1 Cascade 1 choices for diagnosis relative to available resources
Evaluation 15
5.1 Diagnostic criteria 15
5.2 Differential diagnosis 16
Management of IBD 18
6.1 Introduction 18
6.2 Drugs in IBD management 20
6.3 Surgical treatment 27
6.4 Other management options 28
Cascades for IBD management 29

7.1 Cascade 2 UC management 29
7.2 Cascade 3 CD management 30
7.3 Cascade 4 perianal fistulas 31
References
Tables
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
13
32
Highest annual incidence rates and reported prevalence rates for

inflammatory bowel disease 3
World Health Organization diagnostic criteria for Crohns disease 15
Features for differentiating between UC and CD 15
Main differential diagnoses for ulcerative colitis and Crohns disease 16
Distinguishing between tuberculosis and Crohns disease 17
Overview of disease status and drug therapy 26
World Gastroenterology Organization, 2015
IBD 3
Introduction
Inflammatory bowel disease (IBD) is a group of idiopathic chronic inflammatory

intestinal conditions. The two main disease categories are Crohns disease (CD) and
ulcerative colitis (UC), which have both overlapping and distinct clinical and
pathological features.
The pathogenesis of IBD is incompletely understood. Genetic and environmental
factors such as altered luminal bacteria and enhanced intestinal permeability play a
role in the dysregulation of intestinal immunity, leading to gastrointestinal injury.
1.1 Global incidence/prevalence and EastWest differences
A systematic review published in 2012 [1], including data from 167 populationbased studies in Europe (19302008), 52 studies in Asia and the Middle East
(19502008), and 27 studies in North America (19202004), reported the
following incidence and prevalence figures. In time-trend analyses, 75% of CD
studies and 60% of UC studies showed an increasing incidence, which was
statistically significant (P < 0.05). The study did not include data from South
America. The incidence of CD in South America reached an average of 13 per
100,000 rising to 34/100,000 in more developed urban areas in Brazil [2].
Although there are few epidemiologic data from developing countries, the
incidence and prevalence of IBD are increasing with time and in different regions
around the world indicating its emergence as a global disease.
In a recent comparative population-based study from Asia, the incidence of IBD
[3] was found to vary throughout Asia, ranging from 0.54 per 100,000 to 3.44 per
100,000 persons.
In 2004 in Australia, the age-standardized (WHO World Standard Population)
incidence rates of IBD, CD, and UC were 25.2, 16.5, and 7.6/100,000/year,
respectively [4]. In a population-based IBD study in Australia published in 2010
[5], the annual incidence rates were among the highest reported in the literature:
23.536.7 per 100,000 per year.
A 2009 paper [6] gave prevalence data for UC of 64/100,000 and for CD of
21/100,000 in Japan.
Table 1 Highest annual incidence rates and reported prevalence rates for inflammatory
bowel disease
Highest annual incidence (per
100,000 person-years)
Highest reported prevalence

values (per 100,000 persons)
UC
CD
24.3
12.7
505
322
6.3
5.0
114
29
North America
19.2
20.2
249
319
Australasia
11.2
17.4
145
155
Europe
Asia/Middle East
UC
CD
The prevalence of CD appears to be higher in urban areas than in rural areas, and
also higher in higher socio-economic classes. Most studies show that when the
incidence first starts to increase, it is mostly among those of higher social class, but
that the disease becomes more ubiquitous with time.
IBD 4
If individuals migrate to developed countries before adolescence, those initially

belonging to low-incidence populations show a higher incidence of IBD. This is
particularly true for the first generation of these families born in a country with a high
incidence.
One hypothesis for the difference in incidence between developed and developing
nations is the hygiene hypothesis, which suggests that persons less exposed to
childhood infections or unsanitary conditions lose potentially friendly
organisms or organisms that promote regulatory T cell development, or
alternatively do not develop a sufficient immune repertoire, as they do not
encounter noxious organisms [7,8]. Such individuals are associated with a higher
incidence of chronic immune diseases, including IBD.
Other hypotheses for the emergence of IBD in developing nations include
changes to a Western diet and lifestyle (including use of Western approaches to
medication and vaccination) and the importance of such changes early in life.
In developed countries, UC emerged first and then CD followed. In the past
20 years, CD has generally overtaken UC in incidence rates. In developing
countries in which IBD is emerging, UC is typically more common than CD. In
India, for example, there are reports of a UC/CD ratio of 8 : 1 (previously 10 : 1).
One example of the rising incidence of CD once the diseases have been prevalent
for some time is seen in Hong Kong, China, where the UC/CD ratio has dropped
from 8 : 1 to 1 : 1 [9].
The peak age of incidence of CD is in the third decade of life, with a decreasing
incidence rate with age. The incidence rate in UC is quite stable between the third
and seventh decades.
There is a continuing trend toward an increasing incidence and prevalence of IBD
across Asia (particularly in East Asia). Although this is occurring among
developing nations, it is also being seen in Japan, a socio-economically advanced
country.
Although more females than males have CD, the incidence rates among young
children have been higher in males than in females during the past decade, and
over time we may see an equalization of the sex distribution. There is already a
male predominance for CD in studies from East Asia. The sex ratio is already
equal in UC.
1.2 Presenting features of IBD EastWest differences

The presentations of CD and UC are quite similar in such disparate areas of the world
as North America, South America, Europe, Australia, and New Zealand: CD is
distinguished from UC by disease proximal to the colon, perineal disease, fistulas,
histologic granulomas, and full-thickness as opposed to mucosa-limited disease. In
CD, granulomas are evident in up to 50% of patients and fistulas in 25%.
However, there are also differences in presentation between the East and the West.
In East Asia, there is a higher prevalence of males with CD, ileocolonic CD, less
familial clustering, lower rates of surgery, and fewer extraintestinal manifestations.
Primary sclerosing cholangitis (PSC) associated with UC is less prevalent. Overall,
the need for surgery is lower in Asian patients, at around 58%. However, there is a
high rate of penetrating disease and perianal disease in Asia even at diagnosis,
suggesting that complicated disease behavior is not uncommon in East Asia [3,10
12].
IBD 5
In Pakistan, there is much less extraintestinal disease in both UC and CD than is

reported from the West (where up to 25% of patients have extraintestinal
manifestations, if arthralgia is included). In Pakistan, few patients have perianal or
fistulizing disease. In India, the age at presentation of CD is a decade later than in the
West, colonic involvement is more common, and fistulization appears to be less
common.
Tuberculosis is an important differential-diagnostic issue in developing countries.
Numerous genetic loci have been identified that contain susceptibility genes for
IBD. Nearly all of these loci are of absolute low risk, but identifying them is
important for the development of diagnostic markers and therapeutic targets in the
future. Gene mutations known to be implicated in altering the predisposition to CD or
UC have different distributions in different countries of the world, particularly where
there are racial differences [13]. NOD2 mutations are not reported in any of the
studies from Asia [14], whereas polymorphisms in the tumor necrosis factor (TNF)
superfamily 15 gene (TNFSF15) have been found to be associated with CD in East
Asians [15].
Clinical features
2.1 Symptoms
IBD is a chronic, intermittent disease. The symptoms range from mild to severe
during relapses, and they may disappear or decrease during remissions. In general, the
symptoms depend on the segment of the intestinal tract involved.
Symptoms related to inflammatory damage in the digestive tract
Diarrhea:
Stool may contain mucus or blood.
Nocturnal diarrhea.
Incontinence.
Constipation:
May be the primary symptom in UC limited to the rectum (proctitis).
Obstipation with no passage of flatus can be seen in cases of bowel
obstruction.
Pain or rectal bleeding with bowel movement
Bowel movement urgency
Tenesmus
Abdominal cramps and pain:
In the right lower quadrant of the abdomen common in CD, or around the
umbilicus, in the lower left quadrant in moderate to severe UC.
Nausea and vomiting may occur, but more so in CD than UC.
General symptoms associated with UC and CD in some cases
Fever
Loss of appetite
Weight loss
IBD 6
Fatigue
Night sweats
Growth retardation
Primary amenorrhea
Extraintestinal manifestations
Extraintestinal manifestations include musculoskeletal conditions (peripheral or axial
arthropathy), cutaneous conditions (erythema nodosum, pyoderma gangrenosum),
ocular conditions (scleritis, episcleritis, uveitis), and hepatobiliary conditions (PSC).
2.2
Complications
Intestinal complications
Proximal gastrointestinal involvement is a complication, or a different disease

presentation. It may occur more often in children and in some adult ethnic groups
(African-Americans, Ethiopians), but it is also sought more commonly in
children, with whom gastroscopy is a routine early investigation, whereas in
adults it is not [16].
Hemorrhage: profuse bleeding from ulcers occurs in UC. Bleeding is less
common in CD. Massive bleeding in CD is more often seen due to ileal
ulceration than in colitis.
510% of individuals with CD show ulceration in the stomach or duodenum.
Bowel perforation is a concern in CD, and in both CD (if the colon is involved)
and UC if megacolon ensues.
Intra-abdominal abscesses in CD.
Strictures and obstruction (narrowing of the bowel may be due to acute
inflammation and edema, or due top chronic fibrosis):
Strictures in CD are often inflammatory:
Inflammatory strictures can resolve with medical treatment.
Scarring (fixed or fibrotic) strictures may require endoscopic or
surgical intervention to relieve the obstruction.
Colonic strictures in UC are presumed to be malignant until proven
otherwise.
Fistulas and perianal disease:
These are a hallmark of CD.
Surgical intervention is required in cases that do not respond to
medical treatment, or when abscesses have developed. Sometimes
surgical treatment should be pursued concomitantly with medical
therapy, especially in instances of complex fistulas.
There is a high risk of recurrence.
Fistulas to the urinary tract or vagina are not uncommon and can lead to
pneumaturia or fecaluria, or passage of air from the vagina. This may result in
urinary tract infection or gynecological inflammation.
Toxic megacolon:
This is a relatively rare, life-threatening complication of colitis (characterized
by dilation of the colon diagnosed on plain abdominal radiography) that
requires aggressive medical therapy and urgent surgical intervention if there
is no response within 24 h (more common in UC than CD).
IBD 7
Malignancy:
There is a significantly increased risk of colon cancer in UC later than 8 years
after the diagnosis and with uncontrolled disease activity; there is a similar
risk in CD if a substantial area of the colon is involved. The risk increases
relative to disease duration, early age of disease onset, and if there is a family
history of sporadic colorectal cancer. The overall rates of colorectal cancer in
UC have been decreasing in recent reports [17], perhaps due to better use of
drugs that reduce inflammation over time (chemoprevention) and also
because of optimized surveillance [18,19].
Primary sclerosing cholangitis (PSC) in UC is also associated with an
increased risk of cholangiocarcinoma and colorectal cancer. PSC is also
increased in CD, although it is more common in UC.
There is an increased risk of small-bowel adenocarcinoma in small-bowel
CD, but it is rare.
Extraintestinal complications
Extraintestinal complications should be differentiated from extraintestinal

manifestations, and they may be related to disease or to drugs used for IBD
e.g., drug-induced arthropathies (corticosteroids, biologicals); ocular
complications (corticosteroid-induced glaucoma or cataracts); hepatobiliary
complications (gallstones, fatty liver); renal complications (drug-induced
tubulointerstitial nephritis); anemia (iron or vitamin B12 deficiency, or thiopurineinduced cytopenia); bone complications (osteoporosis and fractures); venous
thromboembolic disease; and mood and anxiety disorders.
They affect up to 25% of those with IBD, although 1520% have arthralgias,
while the remainder have frank inflammatory disease in other organ systems.
Some complications may antedate the diagnosis of IBD, and some may run an
independent course from the IBD (even colectomy in UC does not affect the
course of ankylosing spondylitis or primary sclerosing cholangitis although
for many, arthralgia activity parallels the activity of the bowel disease).
Diagnosis of IBD
The diagnosis of IBD in adults requires a comprehensive physical examination and a

review of the patients history. Various tests, including blood tests, stool examination,
endoscopy, biopsies, and imaging studies help exclude other causes and confirm the
diagnosis.
3.1 Patient history
Ask about symptoms diarrhea (blood, mucus), abdominal pain, vomiting,
weight loss, extraintestinal manifestations, fistulas, perianal disease (in CD),
fever.
Inquire as to whether any of the presenting symptoms has occurred at any time in
the past (not uncommonly, flares of disease have gone undiagnosed in the past).
Duration of current complaints, nocturnal awakening, missing work or usual
social activities.
IBD 8
Inquire about possible extraintestinal manifestations including, but not limited

to, arthritis, inflammatory ocular disease, skin diseases, osteoporosis and
fractures, venous thromboembolic disease.
Identify whether mood disorders are present, or stressful situations known to
precipitate IBD.
Recent and past medical problems intestinal infection.
History of tuberculosis (TB) and known TB contacts.
Travel history.
Medications antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and
others like corticosteroids for acne.
Family history (IBD, celiac disease, colorectal cancer, TB).
Cigarette smoking.
3.2 Physical examination

General:
General well-being
Pallor
Cachexia
Clubbing
Nutritional status
Pulse rate and blood pressure
Body temperature
Body weight and height
Abdominal region:
Mass
Distension
Tenderness, rebound, guarding
Altered bowel sounds (obstruction)
Hepatomegaly
Surgical scars
Perianal region:
Tags
Fissures
Fistulas
Abscess
Digital rectal examination (assess for anal strictures, rectal mass)
Extraintestinal inspection mouth, eyes, skin, and joints:
Aphthous ulcers
Arthropathy
Uveitis, episcleritis
Erythema nodosum
Pyoderma gangrenosum
Sweets disease (acute neutrophilic dermatosis)
Primary sclerosing cholangitis (manifestations of chronic liver disease)
Metabolic bone disease
3.3
IBD 9
Laboratory tests
Stool examination
Routine fecal examinations and cultures should be carried out to eliminate

bacterial, viral, or parasitic causes of diarrhea.
Testing for Clostridium difficile (should be considered even in the absence of
antecedent antibiotics) should be carried out within 2 hours of passage of
stools.
A check for occult blood or fecal leukocytes should be carried out if a patient
presents without a history of blood in the stool, as this can strengthen the
indication for lower endoscopy. Where lower endoscopy is readily available,
these tests are rarely indicated.
Lactoferrin, 1-antitrypsin. The main reason for listing this test is to rule out
intestinal inflammation, rather than using it as a positive diagnostic test. It may
not be available in developing countries, but it can be undertaken relatively
inexpensively and easily with rapid-turnaround slide-based enzyme-linked
immunoassay (ELISA) tests.
Calprotectin a simple, reliable, and readily available test for measuring IBD
activity may be better for UC than CD; the rapid fecal calprotectin tests could
be very helpful in developing countries [20]. If available, a home test may be
useful as a routine for follow-up.
Blood examination
Complete blood count (CBC).

Erythrocyte sedimentation rate, C-reactive protein, and orosomucoid; levels
correlate imperfectly with inflammation and disease activity.
Electrolytes and albumin, ferritin (may indicate absorption or loss problems),
calcium, magnesium, vitamin B12.
Serum ferritin may be elevated in active IBD, and may be in the normal range
even in the face of severe iron deficiency. Transferrin saturation can also be
assessed to evaluate anemia. The soluble transferrin receptor (sTFR) assay is also
a good measure of iron stores, although it is expensive (and also involves an
acute-phase protein) and not commonly available.
Decreased serum cobalamin may indicate malabsorption.
Liver enzyme and function testing international normalized ratio (INR),
bilirubin, albumin.
Human immunodeficiency virus (HIV) additional opportunistic infection
work-up, hepatitis B virus (HBV), hepatitis C virus (HCV), varicella zoster virus
(VZV), immunoglobulin G (IgG) [21].
Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and antiSaccharomyces cerevisiae antibodies (ASCA) for cases of unclassified IBD.
Positive p-ANCA and negative ASCA tests suggest UC.
Negative p-ANCA and positive ASCA tests suggest CD.
These tests are unnecessary as screening tests, particularly if endoscopy or
imaging is going to be pursued for more definitive diagnoses. p-ANCA may
be positive in Crohns colitis and hence may not be capable of distinguishing
CD from UC in otherwise unclassified colitis. ASCA is more specific for CD.
These tests may have added value when there may be subtly abnormal
IBD 10
findings, but a definitive diagnosis of inflammatory bowel disease is lacking.

They may also be helpful if considering more advanced endoscopic
techniques such as capsule endoscopy or double-balloon endoscopy, such that
a positive ASCA test may provide stronger reasons for evaluating the small
bowel.
ASCA may not be equally available or affordable everywhere. In countries in
which TB is an important differential diagnosis, ASCA is not helpful for
differentiating small-bowel CD from small-bowel TB. However, if both
ASCA and interferon gamma release assays are available and the ASCA test
is positive and the interferon gamma release assay is negative, the specificity
for CD is high.
There are several other antibody tests, mostly for microbial antigens, that
increase the likelihood of CD either singly, in combination, or as a sum score
of the ELISA results for a cluster of antibodies. These tests are costly and not
widely available. The presence of these antibodies, including a positive
ASCA, would increase the likelihood that an unclassified IBD-like case
represents Crohns disease.
Celiac antibody testing should be pursued unless presentations include obviously
nonceliac features such as fistulas, perineal disease, and blood in the stool.
It is recommended that thiopurine methyl transferase (TPMT) enzyme levels
should be measured prior to initiating thiopurine therapy. In Caucasians, the rate
of mutations at both TPMT alleles, resulting in inadequate TPMT levels, is
approximately 0.3%. The rates of very low to unmeasurable TPMT levels in
other ethnic groups is unknown.
Serum levels of thiopurine metabolites and of circulating levels of biological
agents (to date mostly only available for antibodies to TNF), as well as
circulating levels of antibodies to biological agents, can help guide the dosage
and monitoring of drug adherence.
Excluding intestinal TB in areas with a high pretest probability
Tuberculin purified protein derivative (PPD) skin test. (In some countries, such as
Brazil, the PPD is considered to be positive when > 10 mm; in the USA, it is
positive when > 5 mm)
Serum PPD antibody test.
Interferon gamma assays (QuantiFERON-TB, T-SPOT, TB test). The interferon
gamma release assay (IGRA) has a high specificity for the diagnosis of TB. It
may also be useful for differential diagnosis between gastrointestinal TB (GITB)
and CD in Asian populations [22].
All of these tests may be adversely affected by concurrent immunosuppression
[23].
Simple clinical parameters (such as fever, rectal bleeding, diarrhea, and duration
of symptoms) have the highest accuracy in differentiating CD from GITB [24].
This may be useful if resources are limited.
The combination of endoscopic evaluation and simple radiologic and laboratory
parameters (ASCA, IGRA) is a useful diagnostic aid in differentiating between
CD and intestinal TB [25].
IBD 11
Histopathology
Biopsies are routinely obtained during endoscopy. It is important for the endoscopist
to consider what specific question he or she is asking of the pathologist with each
biopsy sample submitted for evaluation. Some of the important reasons for obtaining
biopsies include:
Assessment of crypt architecture distortion, crypt runting, increased subcryptal

space, basal plasmacytosis. These are features of chronic colitis and would be
atypical in acute infectious colitis.
Assessment of noncaseating granulomas, which would be suggestive of Crohns
disease. Large or necrotic/caseating granulomas should alert the physician to the
a diagnosis of tuberculosis, especially in regions in which TB is endemic.
Identifying histologic changes in areas of normal endoscopy to fully stage the
extent of disease.
Cytomegalovirus (CMV) can be sought on tissue biopsy in patients receiving
immunosuppressive agents or chronic corticosteroids both for RNA, and on
histology in colonic tissue. Serology can be useful as an adjunctive measure
(CMV IgM).
A search for dysplasia can be carried out if routine biopsies are being obtained
for dysplasia surveillance, or if mass lesions are biopsied.
Identifying lymphocytic colitis or collagenous colitis in an otherwise
endoscopically normal-appearing colon. These diagnoses may coexist with smallbowel Crohns disease, and should be sought in patients with diarrhea.
3.4 Imaging and endoscopy

Plain abdominal radiography:
Can establish whether colitis is present and its extent in some cases.
Used when bowel obstruction or perforation is expected.
Excludes toxic megacolon.
Barium double-contrast enema/barium small-bowel radiography:
Not typically recommended in severe cases.
Can be useful for identifying fistulas that arise from or bridge to the colon.
Barium small-bowel radiography is still widely used to assess the
gastrointestinal tract as far as the distal small bowel.
Can provide an anatomic road-map prior to surgery.
Sigmoidoscopy, colonoscopy:
Examine for ulcers, inflammation, bleeding, stenoses.
Multiple biopsies from the colon and terminal ileum.
Colonoscopy in severe or fulminant cases may be limited in extent, due to the
increased risk of perforation.
When there is a lack of response to usual therapy, these examinations can be
used to assess for CMV infection if the patient is receiving chronic
immunosuppressant medication, or for C. difficile infection if stool tests are
equivocal.
A screening colonoscopy for dysplasia surveillance is indicated after 8 years
of UC or Crohns colitis.
The new consensus statement published by the American Society for Gastrointestinal
Endoscopy (ASGE) should be consulted for recommendations on surveillance for and
management of dysplasia in patients with IBD [26]. The new guidelines recommend
IBD 12
chromoendoscopy as the primary surveillance modality, based on its better diagnostic

yield in comparison with random biopsy approaches. However, there is ongoing
debate on whether chromoendoscopy (with dye spraying) is better than highdefinition white-light endoscopy. High-definition endoscopy has represented a clear
advance for identifying raised or irregular lesions. In a recent randomized controlled
trial, high-definition chromoendoscopy was found to significantly improve the rate of
detection of dysplastic lesions in comparison with high-definition white-light
endoscopy in patients with long-standing UC [27], although another trial reported no
difference between chromoendoscopy and high-definition white-light endoscopy [28].
Upper gastrointestinal endoscopy:

In case of upper gastrointestinal symptoms (nausea, vomiting, epigastric
pain). As upper gastrointestinal disease may be more common in pediatric
CD, this is more routine in children.
Capsule endoscopy:
Helpful in patients with suspected CD and negative initial work-up.
Allows evaluation of the entire small intestine, thus improving the diagnosis
and differential diagnosis of IBD [29] lesions found should be interpreted
in the context of the differential diagnosis.
May have a role in known CD assessing disease distribution and the extent
and response to therapy (mucosal healing).
Its current role in UC is still debatable.
For patients with CD who have stenoses or when there is uncertainty
regarding stenosis, a patency capsule can be used first to determine whether
there is a functional structure that would not allow passage of the real capsule
endoscope.
Rarely available and unaffordable in underprivileged countries.
Double-balloon, single-balloon, and spiral enteroscopy:
To assess small-bowel disease when other modalities have been negative and
when a conditions is strongly suspected or if there is a need for biopsies; also
to obtain tissue to rule out TB if the findings are beyond the reach of standard
endoscopy.
To treat small-bowel strictures or for assessment of obscure bleeding in CD.
Rarely available in underprivileged countries.
Other endoscopic advances:
Magnification and chromoendoscopy have the potential to allow more
accurate detection and characterization of dysplastic lesions and assessment
of the severity of mucosal disease in comparison with white-light endoscopy
[29].
Although it can be time-consuming and has limited availability in some
countries, methylene blue staining is relatively inexpensive [30]. It remains to
be proven whether chromoendoscopy is in fact superior to recent highresolution white-light endoscopy techniques.
Magnetic resonance cholangiopancreatography (MRCP):
If there is evidence of cholestasis, or suspected PSC.
Cross-sectional imaging:
Computed tomography (CT), ultrasonography, magnetic resonance imaging
(MRI; including CT enterography and MRI enterography).
IBD 13
Helpful for determining the extent and severity of disease and for assessing
perforating complications of CD. Ultrasound and MRI are preferred, as the
patients are often young and are likely to require repeat imaging over time.
Ultrasound has high level of diagnostic accuracy for detecting CD, especially
in the small bowel and in perianal CD, with relatively low cost and no
radiation exposure [31]. It requires experienced staff.
MRI has high levels of sensitivity and specificity for diagnosing CD in the
small bowel and may be an alternative to endoscopy [32]. It is also useful for
evaluating perianal disease. It is increasingly being used in pediatric patients
and young adults due to the lack of radiation exposure and consequent ability
to repeat the tests safely.
Has replaced barium meal enteroclysis in centers with the appropriate
expertise [33].
MRI of the pelvis is considered the gold standard method for assessing
perineal Crohns fistulas. Endoscopic ultrasonography (EUS) can be
considered if the expertise is available, but its accuracy may be limited by
restricted views.
Dual-energy X-ray absorptiometry (DEXA):
For assessing bone mineral density in selected cases.
Chest radiography:
To exclude pulmonary TB and also to allow a search for free air under the
diaphragm in case of perforation.
Note: it is important to minimize diagnostic medical radiation exposure, due to the

potential risk of radiation-induced malignancy.
3.5 Diagnosis in pediatric patients
The European Society of Pediatric Gastroenterology, Hepatology, and Nutrition
(ESPGHAN) has published the revised Porto criteria for the diagnosis of IBD in
children and adolescents [34]. The revised criteria are based on the original Porto
criteria and the Paris classification of pediatric IBD, incorporating novel data such as
serum and fecal biomarkers. The criteria recommend upper gastrointestinal endoscopy
and ileocolonoscopy in all suspected cases of pediatric IBD, with magnetic resonance
enterography or wireless capsule endoscopy of the small intestine. Imaging is not
necessary if typical UC is diagnosed using endoscopy and histology.
Cascade for IBD diagnosis
4.1
Cascade 1 choices for diagnosis relative to available resources
Limited resources available

1.
Physical examination.
2.
Stool tests for infective sources, fecal leukocytes.
3.
CBC, serum albumin.
4.
HIV and TB testing in high-risk populations and other opportunistic infection

work-up, HBV, HCV, chest X-ray (CXR).
IBD 14
5.
Flexible full-length colonoscopy and ileoscopy with biopsies if histological

interpretation is available.
6.
If endoscopy is not available but barium studies are, then both a small-bowel
barium study and a barium enema should be obtained.
Medium resources available

1.
2.
Stool tests for infection.
3.
Stool for fecal leukocytes, fecal calprotectin (not necessary if endoscopy

available, but may help select for further investigation including with
endoscopy).
4.
CBC, serum albumin, serum ferritin, C-reactive protein (CRP).
5.
HIV and TB testing in high-risk populations serology to HAV, HBV in

patients with known IBD in order to vaccinate if necessary before therapy.
Opportunistic infection work-up, HBV, HCV, VZV IgG, chest X-ray (CXR).
6.
Colonoscopy or ileoscopy, if available.
7.
Abdominal ultrasound scan.
8.
CT scan of the abdomen.
Extensive resources available

1.
2.
Stool tests for infection.
3.
CBC, serum albumin, serum ferritin, CRP.
4.
HIV and TB testing in high-risk populations serology to HAV, HBV in cases

with known IBD to vaccinate prior to therapy, if needed. Opportunistic infection
work-up, HBV, HCV, VZV IgG, chest X-ray (CXR).
5.
Colonoscopy and ileoscopy.
6.
Abdominal ultrasound scan.
7.
Abdominal MRI is preferable to abdominal CT, due to the lack of radiation

exposure.
8.
TB polymerase chain reaction (PCR) testing and culture are essential during
lower endoscopy in areas with a high prevalence of TB.
9.
If there is uncertainty whether the patient has small-bowel disease, crosssectional imaging with MRI, small-bowel capsule endoscopy, or CT should be
carried out.
10. Barium enema if a colonic fistula is expected and not identified on crosssectional imaging, or if colonoscopy is incomplete.
11. In the setting of incomplete colonoscopy, CT colonography has become a
preferred choice for examining the entire colon. Some radiology units have
reservations about pursuing this technique in the setting of CD. Colon capsule
IBD 15
studies are another alternative in cases of incomplete colonoscopy, unless a

colonic stricture is known or highly likely.
12. Capsule endoscopy if the suspected diagnosis of CD is still unclear.
13. Double-balloon endoscopy (antegrade or retrograde, depending on the suspected
site) if areas of the midsmall bowel.
Evaluation
5.1
Diagnostic criteria
Table 2 World Health Organization diagnostic criteria for Crohns disease

Criteria
Clinical
Endoscopy
Discontinuous or
segmental lesions
Cobblestone appearance
or longitudinal ulcer
Transmural inflammation
Biopsy
Resected
specimen
Radiological
Noncaseating
granulomas
Fissures and fistulas
Perianal disorders
Differentiating between UC and CD

Table 3 Features for differentiating between UC and CD
Clinical
Typical UC features
Typical CD features
Frequent small-volume
diarrhea with urgency
Diarrhea accompanied by
abdominal pain and malnutrition
Predominantly bloody
diarrhea
Abdominal mass
Perianal lesions
Endoscopic and
radiological
Diffuse superficial
colonic inflammation
Discontinuous transmural
asymmetric lesions
Involvement of rectum,
but this can be patchy
Mainly involving ileum and rightsided colon
Shallow erosions and

ulcers
Cobblestone appearance
Spontaneous bleeding
Longitudinal ulcer
Deep fissures
Histopathological
Diffuse inflammation in
mucosa or submucosa
Granulomatous inflammation
Serological markers
IBD 16
Typical UC features
Typical CD features
Crypt architecture
distortion
Fissures or aphthous ulcers can be

seen; often transmural inflammation
Antineutrophil
cytoplasmic antibodies
Anti-Saccharomyces cerevisiae and

other antibodies to microbial
antigens
Diagnostic considerations
5.2
Patients should be followed up for 36 months after a first attack if characteristic

clinical, radiological, endoscopic, or histopathological features are lacking.
Repeat colonoscopy can be considered after 1012 weeks to ensure healing,
which is expected in intestinal TB and potentially in CD.
Treatment for TB should be administered and its effects should be observed in
patients in whom there are difficulties in differentiating between CD and
intestinal TB. Treatment for CD and TB should not be carried out
simultaneously.
Colonoscopy findings of diffuse inflammatory changes and negative stool
cultures are not sufficient for a diagnosis of UC. This requires chronic changes
over time (i.e., 6 months, in the absence of other emerging diagnoses) and signs
of chronic inflammation histologically.
Surveillance for colorectal cancer should be implemented in patients with longstanding UC and CD colitis.
The sigmoidoscopic component of the Mayo Score and the ulcerative colitis
endoscopic index of severity show the greatest potential for reliable evaluation of
endoscopic disease activity in UC [35] but these are still mostly used in
clinical trials.
Differential diagnosis
Table 4
Main differential diagnoses for ulcerative colitis and Crohns disease
Main DDs
UC
CD
Acute self-limiting colitis (ASLC)
Intestinal TB
Amebic colitis
Behets disease
Schistosomiasis
UC
CD
NSAID enteropathy
Colon cancer
IBS
IBS (if there are inflammatory

changes, it is not IBS)
Celiac disease
Intestinal TB
NSAID enteropathy
Other DDs
IBD 17
UC
CD
Infectious colitis, ischemic colitis,

radiation colitis, HenochSchnlein
purpura, collagenous or lymphocytic
colitis, Behets disease, colitis
complicated by HIV
Ischemic colitis, microscopic colitis,

radiation colitis, diversion colitis chronic
diverticulitis, and drug-induced
enteropathy (e.g., NSAID), eosinophilic
enteritis, intestinal lymphoma and colon
cancer
CD, Crohns disease; DD, differential diagnosis; HIV, human immunodeficiency virus; IBS,
irritable bowel syndrome; NSAID, nonsteroidal anti-inflammatory drug; TB, tuberculosis; UC,
ulcerative colitis.
IBD and intestinal tuberculosis
Intestinal TB must be excluded before a diagnosis of IBD is made.

A causal association between Mycobacterium paratuberculosis and IBD remains
unproven.
In high-risk populations or jurisdictions, if TB cannot be excluded, a trial of antiTB therapy is justified and corticosteroids should be withheld.
The sequences of symptoms occur as TB: fever, abdominal pain, diarrhea; CD:
abdominal pain, diarrhea, and fever (the latter is often absent).
In the differential diagnosis between TB and CD, TB has a continuous course,
while there is a history of remissions and relapses in CD.
Ascites and hepatosplenomegaly may be present in TB, but are both uncommon
in CD.
Table 5
Distinguishing between tuberculosis and Crohns disease
Features
TB
CD
Clinical
History of TB or current TB
Positive TB contact
Less frequent fistulas, abdominal
abscesses, or perianal involvement
Abnormal CXR (not universal)
Rarely involves the rectum
Fistulas
Bowel wall abscess
Anal perirectal
disorders
Bloody stools
Bowel perforation
Recurrence after
intestinal resection
Endoscopic
Superficial, irregular transverse ulcers

without predominant segmental
distribution
Pseudopolyps
Cecum > ileum
ICV involved (gaping)
May appear similar to

changes in TB
TB features less
common in intestinal TB
(favoring CD):
Longitudinal
ulceration
Cobblestoning
Aphthous ulceration
Ileum > cecum
ICV may be
stenosed or ulcerated
IBD 18
Features
TB
CD
Histopathological
Large, dense, confluent granulomas

Submucosal granulomas
Caseous necrosis and submucosal
stenosis
Caseating changes in intestinal wall and
mesenteric lymph nodes
Positive for acid-fast bacilli
Disproportionate submucosal
inflammation
Bands of epithelioid histiocytes lining
ulcers
Noncaseous
granulomas/necrosis
may be found in up to
50%
Specific tests
Cross-sectional
imaging
TB DNA analysis with TB-specific primer

TB bacteria culture
Tuberculin PPD skin test
Serum PPD antibody test
IFN-gamma assays
Chest radiography for pulmonary TB
ASCA and p-ANCA are of no value in
differentiating the two conditions
ASCA may be useful for differential
diagnosis of intestinal TB and CD [22]
Cecum > ileum
Asymmetric thickening
Ascites
Small pericecal nodes
Mesenteric nodes >1 cm with calcification
and central attenuation
Fat wrapping is unusual
Ileum > cecum

Symmetric thickening
Fat wrapping is
common
Mesenteric nodes 3
8 mm
Enlarged mesenteric
vascular bundles
comb sign
ASCA, anti-Saccharomyces cerevisiae antibodies; CD, Crohns disease; CXR, chest

radiography; ICV, ileocecal valve; IFN, interferon; p-ANCA, perinuclear antineutrophil
cytoplasmic antibody; PPD, purified protein derivative; TB, tuberculosis.
Management of IBD
6.1 Introduction
It is important for the patient to be provided with an explanation about the disease and
individual information. Active patient participation in decision-making is encouraged.
IBD management often requires long-term treatment based on a combination of
drugs to control the disease. Clinicians should be aware of possible drug interactions
and side effects. Often, patients will require surgery, and close collaboration is
required between surgeons and physicians to optimize the patients therapy.
IBD 19
IBD management should be based on:

UC vs. CD (although this is less important for early aspects of treatment)
Disease location and phenotype
Severity
Comorbidities and complications
Individual symptomatic response
Tolerance to medical intervention
Patient access to diagnostic and treatment options
Past disease course and duration, with number of relapses in a calendar year
The goal of treatment is to:
Improve and maintain patients general well-being (optimizing the quality of life,
as seen from the patients perspective)
Treat acute disease:
Eliminate symptoms and minimize side effects and long-term adverse effects
Reduce intestinal inflammation and if possible heal the mucosa
Maintain corticosteroid-free remissions (decreasing the frequency and severity of
recurrences and reliance on corticosteroids)
Prevent complications, hospitalization, and surgery
Maintain good nutritional status
Diet and lifestyle considerations:
The impact of diet on inflammatory activity in UC/CD is poorly understood, but
dietary changes may help reduce symptoms:
During increased disease activity, it is appropriate to decrease the amount of
fiber. Dairy products can be maintained unless not tolerated.
A low-residue diet may decrease the frequency of bowel movements.
A high-residue diet may be indicated in cases of ulcerative proctitis (disease
limited to the rectum, where constipation can be more of a problem than
diarrhea).
There are limited data suggesting that a reduction of dietary fermentable
oligosaccharides, disaccharides, and monosaccharides and polyols
(FODMAP) may reduce the symptoms of IBD [36].
Dietary or lifestyle changes may reduce inflammation in CD:
A liquid diet, pre-digested formula, or nothing by mouth (NPO status) may
reduce obstructive symptoms. Exclusive enteral nutrition can settle symptoms
in inflammatory disease, especially in children; however, how it affects the
inflammation is unknown, since relapse upon stopping enteral nutrition is
common unless some other intervention has been undertaken. It may affect
the gut microbiome, which reverts to baseline once the enteral nutrition is
stopped and the usual table diet is reinitiated.
Enteral nutrition should be considered as an alternative to conventional
corticosteroids to induce remission of CD in children in whom there is a
concern about growth [37] or when immunosuppression is not appropriate
e.g., in difficult-to-control sepsis.
Smoking cessation benefits patients with CD in relation to their disease
course and benefits UC patients from a general health point of view (smoking
cessation is associated with flaring of UC).
6.2
IBD 20
Dietary fiber has potential efficacy for treatment of IBD. There is limited, weak
evidence for efficacy of ispaghula in maintenance of remission of UC and
germinated barley in active UC [38].
Reduction of stress and better stress management may improve symptoms or the
patients approach to their disease. The assistance of a mental health worker may
be useful, and attention to comorbid psychiatric illness is imperative.
Drugs in IBD management
Aminosalicylates anti-inflammatory agents
This group includes:

5-aminosalicylic acid (5-ASA), mesalazine (U.S. Adopted Name
mesalamine).
Preparations available in North America and Western Europe for oral use:
sulfasalazine, mesalamine, olsalazine, mesalazine, balsalazide (in pills,
granules, or multi-matrix preparations); for rectal use: mesalamine enemas
(liquid or foam) and suppositories.
Useful both for treating colitis flare-ups and maintenance of remission.
5-ASA for UC treatment during remissions:
Oral or rectal 5-ASA.
Combination therapy of oral and topical 5-ASA. Combined oral and topical
5-ASAs (mesalamine and sulfasalazine) are more beneficial than oral 5-ASAs
alone for remission of mild to moderate active UC [39].
Rectal 5-ASA is superior to rectal corticosteroids.
Intermittent topical 5-ASAs are superior to oral 5-ASAs for preventing
relapse of quiescent UC [39] for proctosigmoiditis patients.
Data on 5-ASA in CD remain limited:
In patients with mild ileocecal or right-sided colonic CD who decline or
cannot tolerate corticosteroids, or in whom corticosteroids are
contraindicated, 5-ASA should be considered for a first presentation or a
single inflammatory exacerbation in a 12-month period [37].
Do not offer 5-ASA for moderate to severe CD or exacerbations or for
extensive small-bowel disease or disease with penetrating or fibrostenosing
complications [37].
In CD, sulfasalazine and mesalazine/mesalamine are presumed to be mainly
effective in disease affecting the colon. However, this has not been specifically
studied.
Patients receiving sulfasalazine should take folic acid.
It is important to use adequate doses: 2.04.8 g/day for active disease, 2 g/day
for maintenance. However, the evidence for a dose-response effect for 5-ASA
beyond 2 g/day is weak.
Corticosteroids
These usually provide significant suppression of inflammation and rapid relief of

symptoms [40].
Corticosteroids induce remission in patients with a first presentation or a single
inflammatory exacerbation of CD within a 12-month period [37].
They have no role in the maintenance of remission.
IBD 21
Side effects limit (long-term) use.

Concurrent use of calcium and vitamin D is recommended, as well as monitoring
of blood glucose and arterial blood pressure.
In patients with distal ileal, ileocecal, or right-sided CD who decline or cannot
tolerate corticosteroids, or in whom they are contraindicated, budesonide should
be considered for a first presentation or a single inflammatory exacerbation
within a 12-month period [37].
Budesonide may have fewer side effects than conventional corticosteroids [37].
Do not offer budesonide for severe CD or exacerbations [37].
The route of administration depends on the location and severity of the disease:
Intravenous (methylprednisolone, hydrocortisone).
Oral (prednisone, prednisolone, budesonide, dexamethasone).
Rectal (enema, foam preparations, suppository).
Immune modifiers thiopurines
Thiopurines are no more effective than placebo for inducing remission of CD or

UC [41]; they are effective for maintenance of remission induced by
corticosteroids [41].
Do not offer azathioprine or mercaptopurine for CD or UC if thiopurine
methyltransferase activity (TPMT) is deficient. Use at a lower dose if TPMT
activity is below normal [37,42].
If TPMT measurement is not available, the thiopurine dose should be escalated
from 50 mg to the full dose while monitoring the blood count. Asians appear to
require lower doses of thiopurine to achieve efficacy, and the full dosage is
usually limited by the development of cytopenia.
The addition of azathioprine or mercaptopurine to conventional corticosteroids or
budesonide should be considered, in order to induce remission of CD if there are
two or more inflammatory exacerbations within a 1-year period, or if the
corticosteroid dose cannot be tapered and eliminated [37]. It may also be
considered if there are predictors of poor outcome even at the time of diagnosis
(age < 40, corticosteroids for first flare, perianal disease, smoking, perforating
phenotypes).
Thiopurines are associated with low rates of serious infection [41], but should be
monitored more closely in the elderly [43].
Thiopurines increase the risk of lymphoma, although the extent of the increase is
debated [41]. Their use is also associated with an increased risk of nonmelanoma
skin cancer.
Thiopurines in particular are associated with macrophage activation syndrome
(MAS), most likely by promoting viral reactivation through inhibition of natural
killer and cytotoxic T cells [44].
Patients should be monitored for neutropenia if they are taking azathioprine or
mercaptopurine [37], even if TPMT enzyme levels are normal [43].
Azathioprine is used in resource-poor countries in patients with CD and UC
because it is cheap, available, and appears to be safe. Patients often cannot afford
5-ASA and use corticosteroids, and present with severe complications;
azathioprine is a better choice than corticosteroids.
Thiopurine metabolite tests are not available in many countries, but where
available can help explain the lack of response.
IBD 22
Immune modifiers calcineurin inhibitors
Cyclosporine A (CSA) or tacrolimus in UC and tacrolimus in CD.

The tacrolimus level should be measured and a trough of 1015 ng/L [45] should
be aimed for.
Use of CSA is limited to acute (corticosteroid-refractory) severe colitis.
Calcineurin inhibitors are reserved for special circumstances.
Use of CSA is limited almost exclusively to patients with acute severe colitis.
Use of tacrolimus in UC or CD in which other proven therapies have failed.
Calcineurin inhibitors should be discontinued within 6 months to limit
nephrotoxicity, and alternative immunosuppressives such as azathioprine (AZA),
6-mercaptopurine (6-MP), or methotrexate (MTX) will therefore be required if
CSA is being considered.
There is a high colectomy rate 12 months after the introduction of CSA.
After intravenous CSA, there should be a switch to oral therapy when a clinical
response is achieved, and 6-MP, AZA, or MTX should be added.
Immune modifiers methotrexate (MTX) in CD
Methotrexate is more effective than placebo for induction of remission of CD

[41] and for maintenance of remission induced by corticosteroids [41,46].
The addition of methotrexate to conventional corticosteroids or budesonide
should be considered in order to induce remission of CD if patients cannot
tolerate azathioprine or mercaptopurine, or in patients in whom TPMT activity is
deficient if there are two or more inflammatory exacerbations within a 1-year
period, or if the corticosteroid dose cannot be tapered [37].
Methotrexate should only be considered in order to maintain remission of CD in
patients who needed methotrexate to induce remission, or who cannot tolerate or
have contraindications to azathioprine or mercaptopurine [37] MTX should
also be avoided in young women because of pregnancy issues.
Methotrexate is a good option if concomitant therapy with an anti-TNF agent is
undertaken. It has been shown to not have any advantage over placebo in
inducing and maintaining remission in persons with CD who have received highdose corticosteroids and an induction and maintenance regimen with infliximab
over 1 year [47]. However, co-administration with methotrexate can reduce
antibody formation to anti-TNF therapy, and this will likely increase the
sustained response to the anti-TNF. It is considered that the likelihood of
increasing the risk for lymphoma with methotrexate as a single or combination
therapy is less than when thiopurines are used. This risk is considered to be small
[41].
Co-administration of folic acid is recommended.
Hepatotoxicity with methotrexate treatment for IBD is typically mild and
reversible on stopping the drug. Patients should be monitored for hepatotoxicity
at initiation and during treatment with methotrexate [48].
The use of methotrexate in patients with UC is a matter of debate. The recent
METEOR study [49] in France suggested a negative result, but the enrollment
was of a very inactive group and some of the results were suggestive of a positive
outcome. Hence, it may be a viable inexpensive option when there are few or no
other options.
IBD 23
Immune modifiers: uses
Can be used to reduce or eliminate corticosteroid dependence in patients with

IBD.
Can be used in selected patients with IBD when 5-ASAs and corticosteroids are
either ineffective or only partly effective.
Can be used to maintain remission in CD and in UC when 5-ASAs fail.
Can be used in for primary treatment of fistulas.
Are an alternative treatment for CD relapses after corticosteroid therapy.
Can be used in for corticosteroid dependence, to maintain remission and allow
withdrawal of corticosteroids.
Either thiopurines or methotrexate can be used concurrently with biologic therapy
to enhance effectiveness and reduce the likelihood of antibody formation.
Immune modifiers important notes
Do not offer azathioprine, mercaptopurine or methotrexate monotherapy to

induce remission of CD or UC [37].
The onset of action is relatively slow for thiopurines and MTX. It takes
approximately 3 weeks for the dosage of thiopurines to reach blood homeostasis,
and dosing can therefore be accelerated with proper monitoring. The onset of
action is rapid (< 1 week) for CSA.
Thiopurines are not suitable for acute flare-ups. CSA can be effective in acute
severe UC.
Before AZA or 6-MP is started, measurement of the thiopurine methyltransferase
(TPMT) enzyme level (phenotype) will help to guide the dosage, and if enzyme
levels are very low, then the risk may be too high for these drugs to be used.
Where this test is not available, a CBC needs to be obtained at 2 weeks, 4 weeks,
and every 3 months thereafter. Even where the test is available, quarterly CBCs
are still indicated.
Anti-tumor necrosis factor (anti-TNF) agents
This may be the first-line therapy in patients who present with aggressive disease
and in those with perianal CD.
Infliximab, adalimumab, and certolizumab have been approved by the U.S. Food
and Drug Administration (FDA) for the treatment of moderate to severe CD
when there is an inadequate response to standard medications. Infliximab and
adalimumab have been approved in Canada and Europe.
Infliximab and adalimumab show a better clinical response and better remission
and mucosal healing than placebo, with no increase in adverse effects [41,50].
Infliximab, adalimumab, and certolizumab are effective in maintaining remission
of CD induced by anti-TNF agents [41].
Infliximab (IFX) is used for rescue therapy in corticosteroid-refractory severe
UC.
The effects of intravenous IFX treatment last for approximately 8 weeks; regular
scheduled dosing leads to better remission rates than episodic therapy. When
there is a suboptimal response, the dosage can be increased from 5 mg/kg to
10 mg/kg, or the interval can be reduced. Other dosage adjustments can be
tailored to drug levels. Adalimumab and certolizumab are administered
IBD 24
subcutaneously every 2 and 4 weeks, respectively. In the case of adalimumab,

dosing can be increased to weekly if there is a suboptimal response.
The value of combination therapy with thiopurines in both CD and UC has been
confirmed in the SONIC and SUCCESS studies. Concomitant therapy with MTX
is of unproven value, although in patients with rheumatoid arthritis it is known to
reduce immunogenicity when used concomitantly with infliximab. In resourcepoor units, regular scheduled maintenance therapy often remains a distant dream,
and episodic therapy is currently the only option (with the inherent issue of
immunogenicity); see below.
Concomitant administration of immunomodulatory agents reduces the risk of
infliximab antibody development and the risk of infusion reactions [51]. It may
be useful when administered with other anti-TNF agents, but this has not been
formally tested there is a concern, though, about the use of combined therapy
(thiopurines + anti-TNF) in young male patients, because of the increased risk of
hepatosplenic T cell lymphoma [52].
Infliximab is the only proven therapy in the treatment of fistulas, on the basis of
adequately powered randomized controlled trials. Adalimumab is also useful for
fistulas, but these data are only available from subgroups in larger CD studies not
specifically designed to assess the fistula response.
Infliximab treatment reduces hospitalization and surgery rates in patients with
IBD. This significantly reduces the costs associated with the disease [53].
There is only a small increase in malignancy in anti-TNF users [54].
The risk of lymphoma is very low, but this remains a concern. Other cancers may
be increased [41], especially nonmelanoma skin cancers and possibly melanoma.
Treatment of IBD with infliximab, adalimumab, certolizumab, and golimumab
significantly increases the risk of opportunistic infections in comparison with
placebo [55].
The risk of minor and serious infections is of concern. Anti-TNF agents are
associated with low rates of serious infection, but they are associated with
opportunistic infections, including Mycobacterium tuberculosis, histoplasmosis,
coccidiomycosis, and listeriosis [41]. There is an increased risk of reactivation of
latent TB and of hepatitis B, which is endemic in many parts of the developing
world.
If treatments fail or the patients become intolerant of one anti-TNF agent, a
second anti-TNF agent can be effective [56].
Golimumab received regulatory approval in 2013 for the treatment of moderate to
severe UC. There is no increase in adverse effects compared with placebo [50].
Infliximab, adalimumab, golimumab, and certolizumab all induce a sustainable
clinical response in IBD. None of these agents has been proven to be superior to
the others, although the data are more robust with infliximab, especially in UC
[57,58].
In patients treated with infliximab, infliximab antibodies lead to a 26-fold
increase in the risk of infusion reactions [51,55].
Therapeutic drug monitoring (which includes both measurement of circulating
drug levels and also measurement of antibodies to the drug) is more widely
available for infliximab than any other anti-TNF. It can help determine the cause
of a secondary loss of response and may be adopted in dose reduction strategies.
There has been debate as to whether preoperative use of anti-TNFs increases the
surgical risk or the rate of postoperative complications. On balance, this does not
IBD 25
seem to be an important issue, and preoperative use of anti-TNFs should not be a

deterrent against a surgical intervention if it is needed.
Adhesion molecule antagonists
Vedolizumab (an antibody to alpha 4-beta 7) has recently been approved for the
treatment of UC and CD and is effective at both inducing and maintaining
remission. It has few side effects and no known risk for malignancy.
Antibiotics
Metronidazole and ciprofloxacin are the most commonly used antibiotics in CD.
Antibiotics are used to treat CD complications (perianal disease, fistulas,
inflammatory mass, bacterial overgrowth in the setting of strictures).
There has never been an adequately sized randomized controlled trial proving the
efficacy of metronidazole and/or ciprofloxacin in perineal fistulas, but these are
typically first-line therapies.
There is an increased risk for C. difficileassociated disease (CDAD), and
patients presenting with a flare of diarrheal disease should be checked for
C. difficile and other fecal pathogens.
There are no data showing that any antibiotics are effective in UC, but they are
used in the setting of fulminant colitis.
Probiotics
IBD may be caused or aggravated by alterations in the gut flora.

While many patients may use probiotics, there is no evidence that they are
effective in either UC or CD. VSL#3, which is a combination of eight probiotics,
induces and maintains remission of UC [59], and may be as effective as 5-ASA.
However, no such benefit has been demonstrated for CD [60].
There are a few studies that suggest that Escherichia coli Nissle 1917 is not
inferior to low-dose 5-ASA, but response rates were low in these studies. VSL#3
has been shown to reduce flares of pouchitis (post-ileoanal pouch procedure for
UC) in two Italian studies and in one study from both Italy and the UK.
Experimental agents (examples)
UC: anti-adhesion molecules, anticytokine therapies, anti-kinase therapies, antiinflammatory proteins.

CD: anti-adhesion molecules, anticytokine and T cell marker therapies, antikinase therapies, mesenchymal stem cells.
Antisense oligonucleotides/blockers of transforming growth factor- (TGF-)
inhibition.
Symptomatic therapy and supplements
Antidiarrheals such as loperamide (Imodium) if colitis is not fulminant;

cholestyramine if the patient has previously undergone ileal resection.
IBD 26
Analgesics such as acetaminophen, or even codeine if acetaminophen is

insufficient. However, narcotic use should be avoided, as it is associated with
increased mortality in patients with IBD [61].
Nutritional supplementation for those with malnutrition, or during periods of
reduced oral intake.
Vitamin B12 replenishment for those with deficiency.
Vitamin D supplementation if the local area does not allow sun exposure for
much of the year and for patients on thiopurines who are using sunscreens.
Routine vitamin D and calcium supplementation for corticosteroid users.
Routine multivitamin supplementation for all.
For chronic iron-deficiency anemia, parenteral iron should be administered
(either as weekly intramuscular shots or dosing with intravenous iron) if oral iron
is not tolerated.
Disease status and drug therapy

Table 6 Overview of disease status and drug therapy
Mild
Distal UC
Extensive UC
CD
Rectal or oral 5ASA
Topical and oral 5-ASA
Sulfasalazine or other
5-ASA for colonic
disease only
Rectal CS
Metronidazole or
ciprofloxacin for
perineal disease
BUD for ileal and/or
right colon disease
Moderate
Severe
Corticosteroidresistant or
dependent
Rectal or oral 5ASA
Oral CS
Oral GCS
Topical and oral 5-ASA
AZA or 6-MP
Rectal CS
AZA or 6-MP
MTX
Anti-TNF
Anti-TNF
Rectal and oral 5ASA
I.v. CS
Oral or i.v. CS
Oral or intravenous
GCS
I.v. CSA or
Subcutaneous (s.c.) or
i.m. MTX
Rectal CS
I.v. infliximab
I.v. infliximab or s.c.

adalimumab or s.c.
certolizumab
AZA or 6-MP or
preferably anti-TNF
or combination
AZA/6-MP + antiTNF
AZA or 6-MP or antiTNF or preferably

combination AZA/6-MP
AZA or 6-MP or antiTNF or preferably

combination AZA/6-MP
+ Anti-TNF
+ Anti-TNF
Vedolizumab therapy is
another alternative in
moderate/severe
disease
Vedolizumab therapy is
another alternative in
moderate/severe
disease
Quiescent
Distal UC
Extensive UC
CD
Oral or rectal 5-ASA
Oral 5-ASA
AZA or 6-MP or MTX
Oral AZA or 6-MP
Oral AZA or 6-MP
Perianal
IBD 27
Oral antibiotics
AZA or 6-MP
I.v. infliximab
S.c. adalimumab
5-ASA, 5-aminosalicylic acid; 6-MP, 6-mercaptopurine; AZA, azathioprine; BUD, budesonide;

CSA, cyclosporine A; CS, corticosteroid; i.m., intramuscular; i.v., intravenous; MTX,
methotrexate; s.c., subcutaneous; TNF, tumor necrosis factor.
Note: budesonide only for mild to moderate ileal and/or proximal colon disease.
6.3 Surgical treatment

IBD patients may require hospitalization for surgery or for medically refractory
disease this accounts for at least half of the direct costs attributable to IBD.
Surgery in CD
7075% of CD patients require surgery at some point to relieve symptoms if drug

treatment fails, or to correct complications although the incidence of surgery in
CD is falling.
Surgery should be considered as an alternative to medical treatment early in the
disease course for short-segment CD limited to the distal ileum [37].
Surgery is rarely curative in CD; the condition recurs frequently after surgery.
However, surgery can lead to long-lasting remission in some patients with CD.
After surgery, azathioprine and metronidazole should be considered for at least
3 months, as this has been shown to reduce recurrence.
Laparoscopic ileocecal resection has perioperative morbidity rates similar to or
better than those with open surgery for treatment of CD. Convalescence is shorter
with the laparoscopic approach, although the operating time is longer [62].
Balloon dilation may be useful in patients with a single stricture that is short,
straight, and accessible by colonoscopy [37]. It should be ensured that abdominal
surgery is available to manage complications or failure of balloon dilation [37].
Surgical options are:
Drainage of abscesses
Segmental resection
Bowel-sparing stricturoplasty
Ileorectal or ileocolonic anastomosis
Ileocolic resection [63]
Temporary diverting ileostomy/colostomy in severe perianal fistula
Laparoscopic ileocecal resection [62]
Surgery in UC
2530% of UC patients may require surgery if medical treatment is not

completely successful, or in the presence of dysplasia.
Surgical options are:
IBD 28
Total proctocolectomy plus permanent ileostomy.

Ileal pouchanal anastomosis (IPAA).
Segmental resection can be considered for localized neoplasms in the elderly,
or in patients with extensive comorbidity.
Surgery and medication
Corticosteroids:
The dosage should be gradually reduced to prevent surgical complications.
All patients undergoing an ileal or ileocecal resection with a primary anastomosis
for CD should receive metronidazole for at least 3 months postoperatively.
Azathioprine:
No increased risk in a perioperative setting.
Azathioprine and mercaptopurine reduce the need for surgery in CD by 40%.
However, even with treatment with these drugs, approximately 20% of patients
with CD still require surgery at 5 years after diagnosis [64].
Azathioprine or mercaptopurine should be considered in order to maintain
remission of CD after surgery in patients with adverse prognostic factors [37].
Colonoscopy should be considered 6 months postoperatively to escalate therapy
on the basis of the Rutgeerts score [61,65].
Perioperative anti-TNF- therapy with infliximab, adalimumab, or certolizumab:
An increased risk for emergency colectomy is suspected for acute severe colitis.
There is no increased risk in CD.
Preoperative infliximab increases the incidence of early postoperative
complications, particularly infection, in patients with CD. However, the results
need cautious interpretation [66].
Postoperative maintenance in CD with 6-MP/AZA to reduce the frequency and
severity of recurrences. The best data for maintenance are for metronidazole it
is inexpensive and can be considered in resource-poor settings (although limited
by dysgeusia and neuropathic side effects). In contrast, the data for 5-ASA are
weak and it is more expensive, although much better tolerated than
metronidazole.
The importance of stopping smoking should be emphasized to patients this is
the single most effective approach patients can take in order to reduce recurrences
in CD.
Do not offer budesonide or enteral nutrition to maintain remission of CD after
surgery [37].
6.4 Other management options
Marijuana is often used by patients with either CD or UC. Although anecdotally
it may improve symptoms, controlled trials are lacking. A small study from Israel
suggested some benefit.
Many patients stop their therapies over time and remain well in complete
remission for extended periods. Investigators in Manitoba, Canada, showed that
by 5 years of disease, up to 50% of patients may not be using any prescription
medications specifically for their IBD. Many of them are in remission and not
requiring therapy.
IBD 29
Granulocyte and monocyte adsorption apheresis (GMAA) is safe and effective in

the treatment of UC, in comparison with corticosteroid therapy. There are odds
ratios (OR) of 2.23 in favor of GMAA for efficacy and 0.24 in favor of GMAA
for adverse effects. The most frequent adverse effects are reported to be headache
and flushing. None of the patients discontinued treatment [67].
Cascades for IBD management
7.1
Cascade 2 UC management

1.
In endemic areas and when there is limited access to diagnosis, a course of antiameba therapy should be administered.
2.
Sulfasalazine (least expensive) for all mild to moderate colitis and for
maintenance of remission. Different mesalazine preparations are available,
including Asacol 800 mg, Lialda (U.S.), and Mezavant (Europe) 1200 mg pills,
and Pentasa 2 g sachets. These larger once-daily doses can facilitate better
adherence, with no sulfa side effects.
3.
Corticosteroid enemas (especially with a foam vehicle, which is easier to retain

than liquid enemas for distal colon disease). Corticosteroid enemas can
sometimes be made with locally available resources, sometimes at lower cost.
4.
Oral prednisone for moderate to severe disease (acute severe disease requires
intravenous corticosteroids).
5.
If acute severe colitis is unresponsive to intravenous corticosteroids or the patient

has chronic corticosteroid-resistant or corticosteroid-dependent colitis, colectomy
should be considered. This decision needs to be made in a timely fashion in
patients with acute severe ulcerative colitis. Either the Oxford or Swedish
predictors of outcome on day 3 of intravenous corticosteroids can be considered.
6.
CMV and C. difficile should be actively sought in patients with refractory

disease.
7.
Azathioprine for corticosteroid dependence. Methotrexate can be considered if

azathioprine is not available or if there is intolerance, but this is unproven in UC.

1.
Sulfasalazine can be used for mild to moderate colitis.
2.
Asacol 800 mg, Lialda/Mezavant 1200 mg pills, and Pentasa 2 g sachets are now
available and can facilitate better adherence, with no sulfa side effects.
3.
5-ASA enemas or suppositories for distal disease. These can be used for
remission maintenance in distal disease in lieu of oral 5-ASA. Steroid enemas are
also an option, but typically not for maintenance.
4.
Combination therapy with oral and rectal 5-ASA may be more effective in active
distal disease or even active pancolitis.
IBD 30
5.
If remission is not maintained with 5-ASA, then azathioprine or 6-MP/AZA

should be considered; if azathioprine fails, anti-TNF or vedolizumab should be
considered.
6.
If biological agents are available, then depending on the severity of the illness
their use may be indicated instead of trials of immunomodulator monotherapy.

1.
Cyclosporine can be considered in patients with acute severe colitis.
2.
Infliximab can be considered for acute severe colitis or moderately severe

corticosteroid-dependent or corticosteroid-resistant colitis as can adalimumab.
3.
Infliximab or vedolizumab intravenously, or Humira (adalimumab) or golimumab

subcutaneously, are options for ambulatory patients with moderate to severe
disease.
4.
Azathioprine or 6-MP in case of azathioprine failure, anti-TNF or

vedolizumab should be considered.
7.2
Cascade 3 CD management

1.
In endemic areas and when there is limited access to diagnosis, a course of antiameba therapy should be given.
2.
In endemic areas for TB, a trial of anti-TB therapy for 23 months should be
considered in order to determine the response.
3.
Sulfasalazine (least expensive) for all mild to moderate colitis and for
maintenance of remission.
4.
Corticosteroid enemas for distal colon disease. Corticosteroid enemas can

sometimes be made with locally available resources, sometimes at lower cost.
5.
Trial of metronidazole for ileocolonic or colonic disease.
6.
Oral prednisone for moderate to severe disease.
7.
If there is a short segment of small-bowel disease, surgery should be considered.
8.
Azathioprine or methotrexate.
9.
Metronidazole for short-term (3 months) postoperative maintenance after an ileal

resection with a primary ileocolonic anastomosis.

1.
Treat TB and parasites first when diagnosed.
2.
Sulfasalazine for mild to moderate active colonic CD.
3.
Budesonide can be used for mild ileal or ileocolonic disease (right colon).
4.
If remission is not maintained after a course of corticosteroids or if predictors of

poor outcome CD are present, azathioprine (or 6-MP/AZA) should be considered;
in case of azathioprine failure, methotrexate should be considered. Anti-TNF can
IBD 31
also be considered instead of AZA/6-MP or MTX, and these therapies can be

optimized when combined (as proven for AZA/6-MP + infliximab).
5.
Therapeutic monitoring of drug and antibody levels to anti-TNF agents can guide
therapy, especially in the setting of secondary loss of response or if one is
wanting to consider a dose reduction because of prolonged remission.

1.
Infliximab or adalimumab or certolizumab can be considered for moderate to

severe corticosteroid-dependent or corticosteroid-resistant disease.
2.
Immunosuppressive drugs, such as 6-MP and AZA, can also be very helpful in
the treatment of fistulas in CD. These agents have been shown to enhance the
response to infliximab and may be useful when used concomitantly with other
anti-TNF agents by reducing their immunogenicity.
3.
Vedolizumab can be considered when anti-TNF fails.
4.
Therapeutic drug monitoring for biological agents, as noted above.
7.3
Cascade 4 perianal fistulas

1.
Metronidazole.
2.
Surgery, if an abscess is present.
3.
Ciprofloxacin.
4.
A combination of metronidazole and ciprofloxacin. These antibiotics can be used

intermittently for maintenance of fistula closure if tolerated over the long term.
5.
Surgery should be considered early and if long-term maintenance of

antibiotics is required.
6.
Combined medical and surgical therapy provides the best outcome.

1.
Metronidazole.
2.
Surgery, if an abscess is present.
3.
Ciprofloxacin.
4.

for maintenance of fistula closure if tolerated over the long term.
5.

antibiotics is required.
6.
AZA/6-MP for maintenance of fistula closure (rates of long-term closure are not
high).

1.
Metronidazole.
IBD 32
2.
Surgery, if an abscess is present (examination under anesthesia and seton

insertion).
3.
Ciprofloxacin.
4.

for maintenance of fistula closure if tolerated over the long term.
5.

antibiotics is required, and particularly if the fistula is simple.
6.
AZA/6-MP for maintenance of fistula closure.
7.
Infliximab.
8.
Adalimumab for infliximab failure, or as an alternative to infliximab primarily.
9.
Surgery for complex fistulas.
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World Gastroenterology Organisation Global Guidelines

Inflammatory Bowel Disease

WGO Global Guidelines

Cascade for IBD diagnosis 13

Cascades for IBD management 29

Highest annual incidence rates and reported prevalence rates for

World Gastroenterology Organization, 2015

WGO Global Guidelines

Inflammatory bowel disease (IBD) is a group of idiopathic chronic inflammatory

Highest reported prevalence

World Gastroenterology Organization, 2015

WGO Global Guidelines

If individuals migrate to developed countries before adolescence, those initially

1.2 Presenting features of IBD EastWest differences

World Gastroenterology Organization, 2015

WGO Global Guidelines

In Pakistan, there is much less extraintestinal disease in both UC and CD than is

General symptoms associated with UC and CD in some cases

World Gastroenterology Organization, 2015

WGO Global Guidelines

Proximal gastrointestinal involvement is a complication, or a different disease

World Gastroenterology Organization, 2015

WGO Global Guidelines

Extraintestinal complications should be differentiated from extraintestinal

The diagnosis of IBD in adults requires a comprehensive physical examination and a

World Gastroenterology Organization, 2015

WGO Global Guidelines

Inquire about possible extraintestinal manifestations including, but not limited

3.2 Physical examination

World Gastroenterology Organization, 2015

WGO Global Guidelines

Routine fecal examinations and cultures should be carried out to eliminate

Complete blood count (CBC).

World Gastroenterology Organization, 2015

WGO Global Guidelines

findings, but a definitive diagnosis of inflammatory bowel disease is lacking.

Excluding intestinal TB in areas with a high pretest probability

World Gastroenterology Organization, 2015

WGO Global Guidelines

Assessment of crypt architecture distortion, crypt runting, increased subcryptal

3.4 Imaging and endoscopy

World Gastroenterology Organization, 2015

WGO Global Guidelines

chromoendoscopy as the primary surveillance modality, based on its better diagnostic

Upper gastrointestinal endoscopy:

World Gastroenterology Organization, 2015

WGO Global Guidelines

Note: it is important to minimize diagnostic medical radiation exposure, due to the

Cascade for IBD diagnosis

Cascade 1 choices for diagnosis relative to available resources

Limited resources available

Stool tests for infective sources, fecal leukocytes.

CBC, serum albumin.

HIV and TB testing in high-risk populations and other opportunistic infection

World Gastroenterology Organization, 2015

WGO Global Guidelines

Flexible full-length colonoscopy and ileoscopy with biopsies if histological

Medium resources available

Stool tests for infection.

Stool for fecal leukocytes, fecal calprotectin (not necessary if endoscopy

CBC, serum albumin, serum ferritin, C-reactive protein (CRP).

HIV and TB testing in high-risk populations serology to HAV, HBV in

Colonoscopy or ileoscopy, if available.